Provider Choice and Access

Managed care organizations (MCOs) must maintain a network of service providers that is adequate to meet members’ needs. Adequacy in some cases means that members have access to a particular type of service provider within a specified number of miles, or within a drive of a specified number of minutes. In other cases, in order to ensure adequacy and choice, an MCO is required to contract with every willing provider of a certain type.

Contents – To access the full text, please click each sub-topic.

  • MCO must have contracts with at least two HCBS providers per country: Florida a
  • MCO must have contracts with at least two facility-based service providers per county, with at least one licensed bed for each enrollee in applicable enrollment maximum: Florida b
  • MCO must demonstrate adequacy given consumer needs and enrollment: Wisconsin c
  • MCO network must be diverse and flexible: Arizona d
  • Network must be sufficient to assure that care is at least as good as community norms: Arizona e
  • MCO must ensure covered services are provided promptly and are reasonably accessible in terms of location and hours of operation: Arizona f
  • MCO must ensure timely and adequate coverage of medically necessary services required under contract through an out-of-network provider when necessary: Arizona g
  • Services must be as accessible to plan consumers in terms of timeliness, amount, duration and scope as are services provided to non-plan persons within same service area: Arizona h
  • MCO must offer appropriate range of services and accessible services to meet needs of maximum enrollment level, and maintain sufficient number, mix and geographic distribution of providers, including providers who are accepting new Medicaid patients: Florida i
  • MCO must establish mechanisms to ensure network providers comply with timely access requirements, monitor regularly to determine compliance, and take corrective action if there is failure to comply: Florida j
  • MCO must ensure network capacity to serve expected enrollment in service area: Hawaii k
  • Network adequacy is addressed through array of performance indicators that focus on time measures and provider number, mix and geographic distribution: Kansas l
  • Consumers must be divided proportionately between plans: Florida m

  • HCBS are available 7 days a week and for extended hours, as dictated by consumer needs: Florida n, Arizona o
  • MCO must contract with sufficient number of long-term care providers to provide all covered services and ensure that each covered service is provided promptly and is reasonably accessible: Florida p
  • LTSS subcontracts must not be constructed so as to limit network of providers: Wisconsin q
  • For residential care facilities, evidence of adequate capacity includes identification of availability of facilities offering private rooms, and process for moving consumer to private room, if desired, when one becomes available: Wisconsin r
  • Consumers must have access to at least two HCBS service providers: Massachusetts s, Tennessee t

  • Consumer must have access to at least two nursing facilities: Massachusetts u
  • MCO must contract with all current nursing facilities that meet CMS certification requirements, for a minimum of 3 years; after that, MCO must contract with a sufficient number of nursing facilities to have adequate capacity: Tennessee v
  • MCO may not include facility-based service providers from outside region as network providers unless it obtains agency waiver: Florida w

  • State conducts readiness review to assess MCO’s ability to provide services, including review of MCO’s policies and procedures and corresponding documents, provider network and corresponding provider contracts and subcontracts, walk-through of operations, system demonstrations, and interviews with MCO staff: Florida x
  • If MCO does not meet readiness review deadlines, MCO will lose initial enrollment of eligible consumers. If problems remain unfixed, contract will be terminated: Florida y
  • MCO must submit organizational report 60 days before operational start date: Texas ``

  • Material changes in provider network must be approved by state: Arizona aa
  • MCO must notify state within 7 days of any significant changes to regional network: Florida bb
  • Material change to network is one which affects MCO’s ability to meet performance and network standards in contract, or cause more than 5% of consumers to change where services are received: Arizona cc, Florida dd
  • MCO requests for approval of network changes must include description of any short-term gaps identified as result of change: Arizona ee
  • Material change in provider network requires 30 days advance written notice to affected consumers: Arizona ff
  • MCO must notify state within one business day of any unexpected changes that would impair provider network: Arizona gg
  • MCO must document compliance with access requirements after any significant change in operations: Florida hh
  • MCO must have procedures to address network changes that negatively affect ability of consumers to access services, including access to culturally diverse provider network: Florida ii
  • MCO must notify consumer if provider is unavailable to continue to provide services within 10 calendar days from date MCO becomes aware of such unavailability: Florida jj
  • If MCO excludes provider, it must provide written notice to affected consumers 30 days before effective date: Florida kk

  • For LTSS benefits involving intimate personal care or regular home visits, MCO must purchase services from consumer’s choice of any qualified provider who will accept and meet subcontractor provisions: Wisconsin ll
  • MCO must contract with community-based residential facility, residential care apartment complex, community rehabilitation program, home health agency, day service provider, personal care provider, or nursing facility to serve as contracted provider if provider agrees to be reimbursed at MCO’s contract rate and meets all guidelines established by MCO: Wisconsin mm
  • MCO must contract with providers of personal assistance services, and day activity and health services: Texas nn
  • If MCO declines to include provider in network, MCO must give affected provider timely written notice of reason: Arizona oo

  • MCO required to show how many people are within certain distances of providers: Texas pp
  • Transport distance to licensed adult day care must not exceed 20 miles in urban areas, 30 miles in suburban areas, or 60 miles in rural areas: Kansas qq, Tennessee rr
  • For community-based residential alternatives, MCO must demonstrate good faith efforts to have a travel distance of no more than 60 miles between consumer’s community-based residential alternative placement and his or her residence: Tennessee ss
  • Therapy, facility-based hospice, and adult day health care locations must be within average of 30 minutes from consumer’s residence unless waiver granted; in rural areas, standard increased to 60 minutes for therapy services and adult day health care: Florida tt

  • MCO must not prohibit provider from signing with another MCO: Arizona uu, Texas vv
  • Personal care workers must be free to work for any consumer, or work for any agency: Minnesota ww

  • For certain inappropriate behavior, MCO can place consumer on “Administrative Lock-In” and be limited to one hospital, one pharmacy, and/or one service provider: Kansas xx
  • Pursuant to federal regulation, MCO on request must provide information about any physician incentive plan that may affect referrals: Minnesota yy
  1. Fla. Contract, Atch. II, Exh. 7, p. 56.  (back)
  2. Fla. Contract, Atch. II, Exh. 7, p. 59.  (back)
  3. Wis. Contract, pp. 113-15.  (back)
  4. Ariz. Contract, pp. 59-60.  (back)
  5. Ariz. Contract, p. 60.  (back)
  6. Ariz. Contract, p. 60.  (back)
  7. Ariz. Contract, p. 60.  (back)
  8. Ariz. Contract, p. 60.  (back)
  9. Fla. Contract, Atch. II, p. 68.  (back)
  10. Fla. Contract, Atch. II, Exh. 7, p. 60.  (back)
  11. Haw. RFP, p. 76.  (back)
  12. Kan. RFP, p. 44.  (back)
  13. Fla. Contract, Atch. I, pp. 2-3.  (back)
  14. Fla. Contract, Atch. II, Exh. 7, p. 57.  (back)
  15. Ariz. Contract, p. 60.  (back)
  16. Fla. Contract, Atch. II, Exh. 7, p. 55.  (back)
  17. Wis. Contract, p. 101.  (back)
  18. Wis. Contract, p. 114.  (back)
  19. Mass. Contract, p. 41.  (back)
  20. Tenn. Contract, p. 207.  (back)
  21. Mass. Contract, p. 41.  (back)
  22. Tenn. Contract, p. 213.  (back)
  23. Fla. Contract, Atch. II, Exh. 7, p. 60.  (back)
  24. Fla. Contract, Atch. II, p. 41.  (back)
  25. Fla. Contract, Atch. II, p. 41.  (back)
  26. Tex. Contract, p. 7-4.  (back)
  27. Ariz. Contract, p. 66.  (back)
  28. Fla. Contract, Atch. II, p. 71.  (back)
  29. Ariz. Contract, p. 66.  (back)
  30. Fla. Contract, Atch. II, pp. 71-72.  (back)
  31. Ariz. Contract, p. 66.  (back)
  32. Ariz. Contract, p. 66.  (back)
  33. Ariz. Contract, p. 66.  (back)
  34. Fla. Contract, Atch. II, p. 71.  (back)
  35. Fla. Contract, Atch. II, p. 71.  (back)
  36. Fla. Contract, Atch. II, p. 72.  (back)
  37. Fla. Contract, Atch. II, Exh. 7, p. 57.  (back)
  38. Wis. Contract, p. 101.  (back)
  39. Wis. Contract, p. 110.  (back)
  40. Tex. Contract, p. 8-125.  (back)
  41. Ariz. Contract, pp. 61-62.  (back)
  42. Tex. Contract, pp. 4-47 through 4-50.  (back)
  43. Kan. RFP, p. 58.  (back)
  44. Tenn. Contract, p. 469.  (back)
  45. Tenn. Contrct, p. 213.  (back)
  46. Fla. Contract, Atch. II, Exh. 7, p. 59.  (back)
  47. Ariz. Contract, p. 68.  (back)
  48. Tex. Contract, p. 8-28.  (back)
  49. Minn. Contract, p. 138.  (back)
  50. Kan. RFP, p. 80.  (back)
  51. Minn. Contract, p. 225.  (back)

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